Insurance Complaint Form

Date : 25/04/2024

Personal Information

Name *

Complainant Title *

Agency Document*

Nationality*

Identity (ID or Resident Card Number) *

Mobile Phone*

Email *

Copy of the ID Card or Resident Card*

Complaint Information

Complaint Against *

Complaint Against Insurance Company *

Parent Company *

Claim Number (If Any)

Policy Number (If Any)

Insurance Type *

Insurance Complaint Type*

Vehicle Plate Type *

Complainant Type *

Vehicle Plate Characters*

Vehicle Plate Number*

Copy of Car Ownership Card (Attached Only if the Complaint About Car insurance policy)*

Complaint Details

You have TWO options for entering the details:

A textbox to be filled by typing.
Voice recorder button to record details in no more than two minutes. (Voice Recorder is optional)

Details *

Add Document

#	Documents

Agreement

I, the undersigned, admit that all information contained in this application and the documentation provided is true and correct and endurance of all the legal consequences, and that the Authority has the right to use all the information related to the complaint for study, research and development.

Agree